October 24, 2007

New Research on Schizophrenia and Its Effect on Cardiovascular and Heart Disease

Severely mentally ill are at a high risk for cardiovascular disease, says a new research study.

A psychiatrist at Washington University School of Medicine in St. Louis writes in The Journal of the American Medical Association (JAMA) that although mortality from cardiovascular disease has declined in the United States over the past several decades, patients with severe psychiatric illness are not enjoying the benefits of that progress.

In a commentary article in the Oct. 17 issue of JAMA, John W. Newcomer, M.D., reports that those with illnesses such as schizophrenia, bipolar disorder and major depression lose 25 to 30 years of life expectancy compared to the general population. And although suicide does claim the lives of many psychiatric patients, most of those premature deaths are due to cardiovascular disease.

"This is really a double hit," Newcomer says. "Not only are these patients dealing with the serious burden that accompanies their psychiatric disorder, but they also have an increased risk and an increased burden from major medical conditions like diabetes, heart disease (see below) and stroke. Ultimately, it is the unrecognized risk factors and the under-diagnosed and under-treated conditions that significantly shorten the lifespan."

Newcomer says several factors conspire to elevate risk including reduced access to appropriate medical care. Major mental disorders significantly impair a person's ability to work and learn, so patients tend to have lower incomes and poorer dietary habits, often relying instead on fast food. In addition, patients with serious psychiatric illness are much more likely to smoke — between 50 percent and 80 percent smoke cigarettes — and although the severely mentally ill make up only between 5 percent and 10 percent of the population, they consume a disproportionate amount of all cigarettes smoked in the United States. Many psychiatric medications also tend to contribute to weight gain, in part by making people less active and sometimes by stimulating appetite, and weight gain can be a prominent side effect of some antipsychotic drugs in particular.

"All of this adds up," Newcomer says. "They are more likely to eat more high-fat food and to burn fewer calories, so it's not surprising that this population also tends to have higher rates of (being) overweight and obesity."

But that's not the whole story. Newcomer also reports that patients with severe mental illness are significantly less likely to receive therapies of proven benefit for problems with cholesterol, diabetes, hypertension or heart disease. Those who have survived a heart attack are less likely to receive appropriate medications, cardiac catheterization procedures or bypass surgery than heart-attack patients without mental illness.

Regarding preventive care, Newcomer cites data from a national study of 1,500 patients with chronic schizophrenia. They participated in the National Institute of Mental Health-funded Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study. The CATIE study found that 88 percent of patients entering the study with high cholesterol did not take lipid-lowering drugs. Another 30 percent with diabetes at the start of the study received no anti-diabetes medications, and 62 percent of those with high blood pressure were not taking any antihypertensive medication.

Those with severe psychiatric illness also are less likely to be screened for high cholesterol, high blood pressure or diabetes despite the evidence of increased risk in general and specific evidence that some antipsychotic drugs can have adverse effects on body weight, glucose metabolism and lipid levels.

A solution, Newcomer argues, will emerge only if psychiatrists and primary-care providers can work together.

"This requires coordination," he says. "And coordination between psychiatric professionals and primary-care providers is not easy when they often are physically located in different places. There are transportation issues and scheduling issues. For healthy people, the need to make an extra appointment lowers the probability that it will actually happen, and research further indicates that when patients with severe mental disorders have to go across the hall, it reduces the probability they will get care. If they have to cross the street, the probability gets even lower. If it's across town … well, without case managers and others working closely with these patients, in general those follow-ups won't happen."

Newcomer says another problem is that lifestyle interventions that encourage healthy eating, smoking cessation and exercise can be difficult enough in the general population, but they are even more difficult when patients with schizophrenia or other mental disorders are involved. He says such behavioral interventions have been shown to work even in those with severe psychiatric illness, but achieving success requires extra commitment and resources from the health-care community.

Getting psychiatrists to change their routine is important.(...)To lower risk of cardiovascular complications, psychiatrists may need to regularly weigh their patients, take blood pressure and screen appropriately for blood glucose, cholesterol and triglycerides.

"We're not saying psychiatrists should start prescribing lipid-lowering agents or diabetes drugs, but they are on the 'front lines,' seeing psychiatric patients much more than primary-care providers," Newcomer says. "It's important that psychiatrists begin to employ some of these basic screening techniques."

He also says that it's vital that patients with severe mental disorders receive needed psychiatric medications, even though some of those drugs may contribute to weight gain, abnormal lipid levels and risk for cardiovascular disease and diabetes.

"If you have a serious psychiatric condition like schizophrenia, you really need to take medication," Newcomer says. "Clearly we don't want people to stop taking their medicine, but in some cases, there may be alternative drugs that have fewer effects on risk for obesity or diabetes. Combinations of diet, exercise and selected medication are being studied to lower these risks without losing the benefits that antipsychotic drugs provide for these patients with severe psychiatric illness."

(...)If such strategies can be developed and implemented, it is possible to quickly lower rates of cardiovascular disease and increase life expectancy in this population.

Closely related to and as mentioned in this story is the topic of heart disease. For years heart disease has been recognized "as the leading cause of death in the United States." A new story covered in the November 2007 issue of the Harvard Mental Health Letter discusses in detail heart disease and its effect on schizophrenia: Heart disease is "about twice as deadly for people with schizophrenia." The Health Letter examines the increased risk for heart disease as well as preventive methods for people with schizophrenia.

The Health Letter points out that people with schizophrenia in the United States primarily see a psychiatrist or mental health care worker. As a result, they may not be diagnosed with or informed about heart disease. In general--and this is something we’ve covered before--people with schizophrenia should still be seeing their primary care physician for regular check-ups. Another point the Health Letter makes is that of medication non-compliance. Because people with schizophrenia may at times, be reluctant to take their antipsychotic medication routinely, mental health "clinicians may assume that compliance with other medications will also be poor." This may result in a lack of prescription for heart disease medications. Note this is applicable to other areas of health also, i.e., it's important to remember that a diagnosis of schizophrenia is not a reason to overlook other areas of health.

The Health Letter suggests various methods "people with schizophrenia," their clinicians and loved ones can use to help lower their risk for heart disease:

"Control the food environment. Advocate for healthier choices in institutional settings (such as group homes and day treatment programs), and keep healthier foods at home.

Don’t 'kill with kindness.' Family members and clinicians should not turn a blind eye when people with schizophrenia adopt detrimental health habits—such as smoking or indulging in high-calorie foods—simply because these patients face other difficult challenges."

Comments

I have recovered from schizoaffective disorder and lost over 100 lbs. Now I am working in my community Health Department as the Peer Wellness Coordinator and I have made a personal commitment to help improve the longevity of persons who are struggling with mental health disorders. I think that doctors are important, but the solutions really are going to come from us, the folks who have the problems, who reach out to each other, and figure out how to create a new wellness culture among our peers. I have designed a peer-led wellness group, called the LOTUS Group and that stands for Lifestyles
Overcoming Troubles Utilizing
Support. This group includes time for support, relaxation exercises that blood pressure and person centered plans with wellness goals for each participant. It is facilitated by a participant who is in recovery and is a role model.

I do not call us mental health consumers,or patients, I call us participants, because language is so very important. To call us participants means that we are active and making decisions about our lives.

It is my goal to redefine what it means to have a mental illness. I want to say that new things are possible--that there is great hope now and beauty and quality of life can be achieved.

I would like to know your ideas of possibly getting a very dear friend with schizophrenia off of her many drugs (with severe side effects) onto Naturopathic herbs/ "slowly" over a period of 2 months; by replacing the drugs with Niacin Therapy? Her prescribed drugs, alternating with the Niacin.